Proctalgia Fugax

Aka: Proctalgia Fugax, Levator Ani Syndrome, Levator Syndrome, Functional Rectal Pain

1. See Also
   1. Rectal Pain
   2. Pruritus Ani
   3. Lower Gastrointestinal Bleeding
   4. Fecal Incontinence
2. Pathophysiology
   1. Functional Rectal Pain has no clear etiology and is diagnosed after other rectal conditions are excluded
   2. Functional Rectal Pain is divided into three distinct conditions (based on Rome Criteria as below)
      1. Levator Ani Syndrome
      2. Unspecified Functional Anorectal Pain
      3. Proctalgia Fugax
         1. May be related to spasm of anal sphincter
3. Symptoms: Proctalgia Fugax
   1. Anorectal Pain
      1. Sudden onset
      2. Variable character: Sharp, gripping, or cramp-like
      3. No radiation
   2. Spontaneous relief
      1. Seconds to minutes
      2. Rarely lasts hours
   3. Recurs several times each year
      1. Often occurs at night
      2. May occur as often as 3 to 4 times weekly
   4. Associated Symptoms
      1. Urge to defecate but no stool passed
      2. Onset with orgasm
4. Diagnosis: Proctalgia Fugax (ROME IV Criteria - all must be present for diagnosis)
   1. Recurrent episodic Rectal Pain, unrelated to Defecation
   2. Episode duration seconds to minutes (<30 minutes)
   3. No Anorectal Pain between episodes
   4. Other organic causes of Rectal Pain are excluded
5. Diagnosis: Levator Ani Syndrome (ROME IV Criteria - all must be present for diagnosis)
   1. Chronic or recurrent Rectal Pain or ache
   2. Episode duration >30 minutes
   3. Pain on posterior traction (against puborectalis muscle) on rectal exam
   4. Other organic causes of Rectal Pain are excluded
6. Diagnosis: Unspecified Functional Anorectal Pain (ROME IV Criteria - all must be present for diagnosis)
   1. Chronic or recurrent Rectal Pain or ache
   2. Episode duration >30 minutes
   3. NO Pain on posterior traction (against puborectalis muscle) on rectal exam
      1. Differentiates this condition from Levator Ani Syndrome
   4. Other organic causes of Rectal Pain are excluded
7. Differential Diagnosis
   1. See Rectal Pain
8. Associated Conditions
   1. More common in those with Irritable Bowel Syndrome
   2. Potential food associations
      1. Artificial Sweeteners
      2. Caffeine
9. Management: General to consider in all Functional Rectal Pain
   1. Exclude organic causes of Rectal Pain
   2. Sit in tub of hot water
   3. Fiber supplementation (e.g. 20-30 grams/day) with 64 ounces non-caffeinated fluid
   4. Biofeedback
   5. Topical Diltiazem or topical Glyceryl Trinitrate
      1. See Anal Fissure for dosing
   6. Tricyclic Antidepressants
10. Management: Proctalgia Fugax
    1. No proven Management
    2. Medications with anecdotal success (no proven efficacy)
       1. Albuterol MDI
       2. Catapres 0.1 mg bid
       3. Cardizem 80 mg PO bid
       4. Diazepam (Valium) at bedtime (not recommended)
    3. Procedures that have been studied with varying success
       1. Onabotulinumtoxin A injection
       2. Sacral nerve stimulation
       3. Pudendal Nerve Block
    4. Maneuvers that anecdotally interrupt spasm
       1. Sit in tub of hot water
       2. Apply ice to peri-anal area
       3. Finger placed inside Rectum
       4. Rectal suppository (e.g. Preparation H)
       5. Inhaled Salbutamol (not available in U.S.)
11. References
    1. Cohee (2020) Am Fam Physician 101(1):24-33 [PubMed]
    2. de Parades (2007) Dis Colon Rect 50(6): 893-8 [PubMed]